<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>Title</title>
</head>
<body>
    <input type="hidden" name="rid">
<form class="layui-form" lay-filter="userForm" id="update_user_form" action="" style="padding:15px 10px;">
    <div class="layui-row">
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">患者姓名</label>
                <div class="layui-input-block">
                    <input type="text" name="rname" required  lay-verify="required" placeholder="患者" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">病单号</label>
                <div class="layui-input-block">
                    <input type="text" id="dis" name="disoddid"  lay-verify="required" disabled placeholder="" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
    </div>


    <div class="layui-row">
        <div class="layui-col-xs5">
            <div class="layui-form-item">
                <label class="layui-form-label">身份证号</label>
                <div class="layui-input-block">
                    <input type="text" name="idnumber" required  lay-verify="required" placeholder="身份证号" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs5">
            <div class="layui-form-item">
                <label class="layui-form-label">手机号</label>
                <div class="layui-input-block">
                    <input type="text" name="phone" required lay-verify="required" placeholder="手机号" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs2">
            <div class="layui-form-item">
                <label class="layui-form-label">性别</label>
                <div class="layui-input-block">
                    <input type="text" name="sex" required  lay-verify="required" placeholder="性别" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
    </div>


    <div class="layui-row">
        <div class="layui-col-xs4">
            <div class="layui-form-item">
                <label class="layui-form-label">诊断项目</label>
                <div class="layui-input-block">
                    <input type="text" name="operid" required  lay-verify="required" placeholder="诊断项目" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs4">
            <div class="layui-form-item">
                <label class="layui-form-label">就诊时间</label>
                <div class="layui-input-block">
                    <input type="text" name="retime" required  lay-verify="required" placeholder="就诊时间" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs4">
            <div class="layui-form-item">
                <label class="layui-form-label">结束时间</label>
                <div class="layui-input-block">
                    <input type="text" name="retimeall" required  lay-verify="required" placeholder="结束时间" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
    </div>

    <div class="layui-row">
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">预约医生</label>
                <div class="layui-input-block">
                    <input type="text" name="medid" required  lay-verify="required" placeholder="医生" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">挂号费</label>
                <div class="layui-input-block">
                    <input type="text" name="fee" required  lay-verify="required" placeholder="挂号费" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
    </div>

    <div class="layui-form-item">
        <label class="layui-form-label">备注</label>
        <div class="layui-input-block">
            <input type="text" name="remarks" required  lay-verify="required" placeholder="备注" autocomplete="off" class="layui-input">
        </div>
    </div>
    <div class="layui-row">
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">状态</label>
                <div class="layui-input-block">
                    <input type="text" name="typeid" required  lay-verify="required" placeholder="状态" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
        <div class="layui-col-xs6">
            <div class="layui-form-item">
                <label class="layui-form-label">客户</label>
                <div class="layui-input-block">
                    <input type="text" name="cid" required  lay-verify="required" placeholder="客户" autocomplete="off" class="layui-input">
                </div>
            </div>
        </div>
    </div>
</form>

</body>
</html>